A pediatric nurse is emotionally distraught by the death of a 9-year-old girl who received care on the unit over the course of many admissions spanning several years. What action is the most appropriate response to the nurses own grief?
- A. Take time off from work to mourn the death.
- B. Post mementos of the patient on the unit.
- C. Solicit emotional support from the patients family.
- D. Attend the patients memorial service.
Correct Answer: A
Rationale: The correct answer is A because taking time off from work to mourn allows the nurse to process their emotions and prevent burnout. This self-care step promotes mental well-being and helps prevent the nurse from being overwhelmed by their grief.
Choice B is incorrect as it may prolong the grieving process and create a constant reminder of the loss. Choice C could potentially burden the patient's family with the nurse's grief, making it an inappropriate action. Choice D, attending the memorial service, may be emotionally challenging and may not provide the nurse with the necessary space to cope with their grief effectively.
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The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
- A. Privately ask the son to allow the patient to make his own health care decisions.
- B. Explain to the patient that he is responsible for his own decisions.
- C. Work with the team to negotiate informed consent.
- D. Avoid divulging information to the eldest son.
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights.
Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
- A. Drowsiness
- B. Urinary output of 20 mL/hour
- C. Normal deep tendon reflexes
- D. Respiratory rate of 10 to 12 breaths per minute
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?
- A. Periodically apply ice to the area.
- B. Keep the area cleanly shaven.
- C. Apply petroleum jelly to the affected area.
- D. Avoid using soap on the treatment area.
Correct Answer: C
Rationale: The correct answer is C: Apply petroleum jelly to the affected area. This is because petroleum jelly helps to soothe and protect the skin, reducing dryness and irritation caused by radiation therapy. Ice (A) can further damage the skin, shaving (B) can increase the risk of infection, and soap (D) can be too harsh on the sensitive skin. Therefore, instructing the patient to apply petroleum jelly is the most appropriate recommendation to promote skin healing and comfort.
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?
- A. Instill nonliquid medications without diluting.
- B. Irrigate the tube with 60 mL of water after all medications are given.
- C. Mix all medications together to decrease the number of administrations.
- D. Check with the pharmacy for availability of the liquid forms of medications.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions.
Summary of Incorrect Choices:
A: Instilling nonliquid medications without diluting can increase the risk of tube clogging.
B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube.
C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.
A nurse exchanges information with the oncomingnurse about a patient’s care. Which action did the nurse complete?
- A. A verbal report
- B. An electronic record entry
- C. A referral
- D. An acuity rating
Correct Answer: A
Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.